North Derbyshire Homeless Pathway referral form This form is to be used to refer single clients from the Bolsover, Chesterfield & North East Derbyshire areas who appear to be Homeless or threatened with Homelessness in 56 days. If the client is homeless or due to be homeless on the same day Tel 01246 498204 immediately. Referring organisation statement & permission - You have told us that you are either homeless or threatened with homelessness within 56 days. In order to help you either remain in your current accommodation or find new accommodation we have to inform the relevant local authority homelessness & housing options service in accordance with the Homelessness Reduction Act 2017. We need your consent to make a referral to the relevant local authority. If you choose to give your consent then we will complete the information on this form and send this to the local authority for them to start making enquiries on your behalf prior to them contacting you to discuss your situation with you. The information will also allow them to form a basic assessment of how they will be able to help you. Client consent - I give permission for the referring organisation to make a referral on my behalf to the relevant local authority to allow them to help me with my housing situation. I understand that I can withdraw my consent at any time by contacting the relevant local authority.
Name:
Date: Signed:
Referring Agency details
Referrers name: Telephone number:
Email address:
Reason for Referral/ Comments (include Advocate details if appropriate):
Clients details
Name (preferred name): Age:
National Insurance number: Date of birth:
Current address:
Contact details
Telephone number:
Email address:
Household make up:
Homeless / Threatened Homelessness
Date of potential homelessness:
Reason for potential/ actual homelessness: Support Needs
Identified support needs: Support Worker (if different from referral). Name:
Contact details:
Risk Assessments - Potential risks to self, public agencies: YES NO Details of risk:
Income/ Benefits - Is the Client in receipt of benefits? YES NO If YES, outline please specify what benefits are received and amounts - include pip payments:
If NO, detail income:
To the referrer Please email a copy of this form with any supporting evidence to Pathways of Chesterfield as shown below and ensure that your client has agreed for their details to be passed on (see below). Select the applicable local authority where the client has a local connection:
Bolsover District Council [email protected]
Chesterfield Borough Council [email protected] North East Derbyshire [email protected] Send your referral to: Pathways of Chesterfield [email protected] and copy in the applicable local authority homeless prevention team (Pathways of Chesterfield), 120 Saltergate, Chesterfield, S40 1NG. Tel: 01246 498204. Declaration of information I understand the following: You will use the information I have provided to either prevent me from becoming homeless or to provide relief if I am actually homeless. You may check some of the information with other sources within the council, the rent service, other councils and government departments e.g. the DWP, Inland Revenue Home Office and the Ministry of Housing, Communities and Local Government. You may also get information about me from certain other organisations, or give information about me to them to: make sure the information is accurate; prevent or detect crime; and protect public funds. These other organisations include government departments, other local authorities and private sector organisations such as banks and organisations that may assist with my housing. If I give information that is incorrect or incomplete you may take action against me, including court action. I declare that the information I have given on this form is correct and complete.
Signature of Date: client being referred:
Using your personal information: For more information on how we use personal information please go to our privacy statement on our website www. bolsover.gov.uk / www.ne-derbyshire. Designed by North East Derbyshire District Council gov.uk / www.chesterfield.gov.uk